The bubonic plague season arrived in Madagascar earlier than usual in 2013, and with it an apparently greater prevalence of a more deadly strain of the disease.
Between September and December the health ministry reported 42 known deaths and 84 cases from the illness in four of the country’s 112 districts. The cases have been recorded at various geographical locations: Mandritsara in the north, Soanierana Ivongo in the northwest, Ikongo in the southwest, and Tsiroanomandidy in the central highlands.
Popularly known as the Black Death in reference to the colour of the buboes - infected lymph nodes - that are characteristic of the disease, plague is caused by the bacterium Yersinia pestis and has been around for millennia. It is carried by infected fleas that transmit the bacteria when they bite humans. The fleas on rats and other rodents are the primary vector, although other animals and insects can also transport the bacteria.
Dr Voahangy Ravaoalimalala, vice-director of the Malagasy Institut Pasteur, which performs pathogen tests for the health ministry in Antananarivo, told IRIN: "Bubonic plague can be treated easily with antibiotics, and it takes longer to develop, but this time some cases of pneumonic plague have also been identified. This form of plague is harder to treat, as it can kill people within three days."
Most cases of the three common plague strains are bubonic. Between two and eight days after infection the patient develops fever and chills, as well as the swelling of lymph nodes – the buboes – to which the bacteria move and where they multiply. The second is septicaemic plague, with a fatality rate of 50 percent - higher than bubonic - and the third is pneumonic plague, which is fatal in all cases unless the patient is given antibiotics as soon as the symptoms appear.
The health ministry notes that between 300 and 600 cases of bubonic plague occur annually in Madagascar, usually between October and March. Despite some anxiety in the capital, Antananarivo, and local media reports that there was a suspected case of plague in Manjakandriana, 20km from the densely populated city, the cases and fatalities have occurred in fairly isolated areas.
Two weeks ago, officials announced Antananarivo’s coffers were empty and there was no money to spare for rubbish collection. Refuse has been piling up in the city, encouraging the spread of rats and mice. The UN Development Programme (UNDP) and the European Union (EU) have donated money and equipment, and have mobilized volunteers to assist in clearing the city of garbage.
Donor funding – apart from emergency assistance - to Madagascar was frozen in the wake of a coup in March 2009, when Andry Rajoelina seized power from twice-elected President Marc Ravalomanana with the backing of the military. To compensate for the financial shortfall in the donor-dependent nation, Rajoelina’s government ushered in severe cutbacks to public services, including the health sector.
If the second round of presidential elections - on 20 December 2013 - is deemed free and fair, donor funding to the country should be unlocked.
In 2011 Victorine Raheliarinoro, 52, a mother of four farming rice in the highland village of Antandrohomby, 35km east of Antananarivo, took her eight-year-old daughter to the nearest clinic, about 5km away, after she developed a fever. The doctor noticed the girl had swollen lymph nodes. He suspected bubonic plague and prescribed antibiotics. When another boy in the village became ill and was taken to the hospital, health officials descended on the village.
“They gave medicine to everybody in the family and sprayed our houses with insecticides,” Raheliarinoro told IRIN. Both children recovered and the illness was stopped from spreading. “I heard on the radio that many people have died of the plague in the north, so I tell the children to stay clean. We also clean the house and the courtyard every day so rats can’t get in,” she said
According to the World Health Organization (WHO), 21,725 persons were infected with plague worldwide in the first decade of the 21st century, accounting for 1,612 deaths and a case fatality rate of 7.4 percent.
In many countries the disease has retreated as a result of access to medication, rodent-proof housing and better urban hygiene, but living conditions in Madagascar’s highland villages - where people often store their rice crops in their homes - attract rats and make the country more prone to plague outbreaks.
According to WHO, bubonic plague is endemic in many parts of Africa, and “the most heavily affected African countries are the Democratic Republic of the Congo, Madagascar, Mozambique, Uganda and the United Republic of Tanzania”
Ravaoalimalala, of the Malagasy Institut Pasteur and who previously worked for Madagascar’s public health department in the 1980s, said it was routine for the government to have public health campaigns about the disease ahead of and during the plague season, telling people to contact health authorities as soon as they see dead rats, or two people die of a mysterious illness in the village or in a family.
In general, the system works. “This year, either the message didn’t go out, or people didn’t listen,” she told IRIN. “Every year, they manage to find the cases of plague and make sure there is no epidemic.”
Health officials also have to combat superstitions about the disease, “especially in remote villages, [where] people think plague is caused by a curse. They think the neighbours put a bad spell on them, so they go to see a traditional healer. Some of these healers open the swelling of the lymph node, and try to suck out the evil spirit, causing them to become ill also,” Ravaoalimalala said.
Plague is thought to have arrived in Madagascar in 1898, carried by infected rats on ships from India. As a result of vaccination campaigns, improved housing and public hygiene, and the discovery of streptomycin and the use of insecticides, plague was brought under control in the 1950s.
During the next 30 years, only 20 to 50 cases per year were reported in Madagascar, but since 1989 the number of suspected cases has increased steadily. According to the Centres for Disease Control and Prevention in the US, approximately five million people are exposed to plague in Madagascar’s plateaus.